Please list ALL applicants for criminal records search.  You must enter the County and State or if statewide is needed enter 'Statewide in ??' in which to perform the search.  When finished, please enter the date sent and the total amount of requests in the boxes at bottom of this form.

Name of Applicant:(L, F, M)               SSN(000-00-0000)   DOB ex 02/16/1967   County, State ex: Cook County, IL 
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      

Your ACCOUNT NUMBER:

Today's Date:          TOTAL Records requested:

Please verify the information you are submitting.  We cannot be responsible for typographical errors.

If possible, please print this form once completed and fax to 1 888 867-4202